A nurse is caring for a client who is in physical restraints. Which of the following actions by the client indicates the restraints can be discontinued?
The client apologizes for their prior behavior.
The client remains in control of their actions.
The client asks to be released from the restraints.
The client signs a behavioral contract.
The Correct Answer is B
Choice A reason:
An apology from the client for their prior behavior, while it may be a positive step towards recovery, does not necessarily indicate that they have regained control over their actions or that they no longer pose a risk to themselves or others. The decision to discontinue restraints should be based on current behavior and risk assessment rather than past actions.
Choice B reason:
The primary goal of using physical restraints is to prevent harm to the patient or others when less restrictive interventions are not effective. If the client demonstrates control over their actions, it suggests that they are no longer at immediate risk of harm, and therefore, discontinuing restraints could be considered³⁴⁵. This aligns with guidelines that advocate for restraint use to be continually assessed and reduced or discontinued as soon as possible.
Choice C reason:
While a request to be released from restraints indicates a desire for freedom, it does not provide enough information about the client's current mental state or risk of harm. The healthcare team must assess whether the client's condition has improved to a point where restraints are no longer necessary.
Choice D reason:
Signing a behavioral contract is a positive step towards establishing trust and setting expectations for behavior. However, it is not an immediate indication that the client can safely have restraints removed. The effectiveness of such contracts depends on the individual's ability to understand and adhere to the agreed-upon behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Excessive sleep or a significant change in sleep patterns can be an indicator of a relapse in schizophrenia. Schizophrenia can disrupt the regular sleep-wake cycle, leading to either insomnia or hypersomnia (excessive sleep). When a client with schizophrenia begins sleeping more than usual, it may suggest a worsening of symptoms or an impending relapse. It's essential for the nurse to include this information in the discharge teaching so that the family can monitor and seek help if the client's sleep patterns change significantly.
Choice B reason:
An inability to concentrate is another potential sign of a relapse in schizophrenia. Cognitive difficulties, including problems with concentration, are common in schizophrenia and can worsen during a relapse. This symptom can affect the client's ability to function daily and adhere to treatment plans. Therefore, it is crucial for the nurse to educate the family about this sign so they can recognize it early and consult with healthcare providers.
Choice C reason:
Exhibiting an inflated sense of self is not typically associated with schizophrenia relapse. While some individuals with schizophrenia might experience grandiose delusions, an inflated sense of self is not a common or specific sign of relapse. The family should be aware of more characteristic symptoms such as changes in sleep, concentration, mood, or behavior.
Choice D reason:
Increasing participation in social activities is generally not a sign of relapse in schizophrenia; in fact, it is often encouraged as part of the recovery process. Social withdrawal, rather than increased participation, would be more concerning and could indicate a relapse. It's important for families to support the client's social engagement as it can be beneficial for their overall well-being.
Correct Answer is C
Explanation
Choice A reason:
Asking the client's family to encourage the client to receive ECT may be a supportive measure, but it should not be the first action taken. The client's autonomy and right to refuse treatment must be respected, even if they are involuntarily committed. Family members can be involved in the discussion, but the client's decision should be paramount.
Choice B reason:
Telling the client they cannot refuse treatment because they were involuntarily committed is incorrect. Involuntary commitment does not automatically override a client's right to refuse treatment. Clients have the right to be informed about their treatment and to refuse it unless specific legal criteria are met.
Choice C reason:
Documenting the client's refusal of the treatment in the medical record is the correct action. It is essential to record the client's decision and the discussion surrounding it. This documentation ensures that the client's rights are respected and provides a legal record of the interaction.
Choice D reason:
Informing the client that ECT does not require client consent is incorrect and unethical. Consent is a fundamental patient right, and all clients, including those involuntarily committed, have the right to be informed about their treatment options and to give or withhold consent unless they are legally deemed incompetent to make such decisions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today